Medical HistoryPlease complete the form below and submit before your first appointment. Owner name * First Name Last Name Pet insurance / policy # PET INFORMATION Pet name * Breed * Sex * Select one Male Female Spayed / neutered? * Select one Yes No Color * Age * HEALTH HISTORY Length of ownership * How did you aquire your pet? * Select one Adopted Breeder Pet Store Private Home Shelter Stray Other Additional pets in home Please list all. Where does your pet stay? * Select one Inside Outside Both Is your pet microchipped? * Select one Yes No Pets typical temperament or behavior * Known allergies (environmental, flea, food, etc.) If any, please list. Previous surgeries, medical problems or chronic issues * Current medications If any, please list. Current flea / heartworm preventatives If any, please list products. Previous veterinarian TRAVEL HISTORY If your pet has travelled or lived outside of Oregon, please specify. Does you pet get boarded or groomed? Select one Yes No REPRODUCTIVE HISTORY If your pet spayed / neutered, at what age? If your patient is intact, have they bred previously? Select one Yes No If so, how many litters has your pet had? When was the last litter? MM DD YYYY When was their last heat cycle? MM DD YYYY Any history of a blood transfusion? Select one Yes No If yes, please list when. MM DD YYYY Your form has been sent successfully. Please be sure you have also completed the New Client Information Form before your first visit.
